California ERs serving African-Americans likelier to close: study

NEW YORK (Reuters Health) – Hospitals in California that served a greater proportion of black patients were more likely to shutter their emergency departments in the past decade than hospitals with fewer black patients, according to a new study.

Also at a higher risk of closure were EDs serving a greater proportion of patients on Medicaid or those in hospitals that operated on a for-profit model.

“This should be disturbing to people,” said Dr. Renee Hsia, lead author of the study and a professor at the University of California, San Francisco.

“People who don’t have an emergency room in their neighborhood, it’s not like their emergency disappeared,” she told Reuters Health.

Hsia and her colleagues analyzed every emergency department closure in California from 1998 to 2008.

Twenty-nine out of 401 EDs — 7.2 percent of the state’s total — closed during the 10-year period.

Among the hospitals that closed their EDs, 1.87 percent of the patients served were black, compared to 1.13 percent of patients at EDs that remained open.

Also, 28 percent of the patients at the shuttered emergency departments used Medi-Cal state health insurance, compared to 20 percent of patients at the EDs that stayed in operation.

Most of the closures were clustered in Los Angeles County, “which may contribute to the relationship observed between ED closures and black patients because LA County also has a higher proportion of black individuals compared with the remainder of California,” the authors note in their study.

“I think that the closures are a reflection of economics a lot more than they are about race,” said Dr. Wesley Fields, chair of the Emergency Medicine Action Fund and a clinical professor at the University of California, Irvine.

For one, the researchers did not find a correlation between California’s two largest minorities, Hispanics and Asians, and emergency department closures, Fields noted in an email.

Secondly, said Fields, who was not involved in the new study, hospitals have been consolidating to boost their efficiency and volume like any other service industry.

“Nearly all hospitals operate in the private sector, even (if) they are non-profit, and gravitate into areas with higher household income and a greater chance of operating profitably, leaving behind lower income areas,” Fields said.

Hsia notes that hospitals in poorer neighborhoods could have a harder time recruiting staff and might struggle with sicker patients and patients with more complicated conditions.

“The general implication is, I think, that we do need more government oversight and regulation of emergency room closures and access to health care,” Hsia said.

Fields said many state or federal statutes prohibit racial and economic discrimination by hospitals against individuals, but there are no laws that can force hospitals to remain in operation at a financial loss indefinitely.

The study did not determine whether the emergency department closures had a negative impact on the health of the people who lived in the area.

The degree to which California’s pattern of ED closures reflects national trends is also unclear.

In an editorial accompanying the study, Fields cites other research that found total emergency department bed capacity in California increased from 2000 to 2007 despite the ED closures, and that 88 percent of the patients in the closure areas had to travel less than five extra miles to reach the next closest emergency room.

The challenge now, he wrote, is “to define how we add value for the entire US population at the interface between communities and advanced hospital care and how the ED can better integrate care for populations that are underserved or affect public health with community-based providers.”

Fields told Reuters Health, “I think policy makers would rather shift resources to medical homes and community clinics than try to keep open every” emergency department.